Krishna J. Chari, Psy.D Clinical Psychologist Pain Consultation and Treatment Center University of New Mexico Hospitals Assistant Professor,

Transcription

1 Krishna J. Chari, Psy.D Clinical Psychologist Pain Consultation and Treatment Center University of New Mexico Hospitals Assistant Professor, Department of Psychiatry University of New Mexico

2 Course of presentation Overview of the pain system. Psychological trauma: key points and intersection with health and pain. Intervention and tools for practicing physicians.

3 The generation of pain in response to injury involves 4 basic elements: Transduction: Transmission:

4 Transformation or Plasticity:

5 Pain perception:

6 Spinothalamic tract. Spinoreticular tract.

7 Cortical projection: (Bushnell, Ceko, & Low. 2013)

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9 Pain thus represents a final integrative package, the components of which consist of neurobiological processes, as well as contextual, psychological, and sociocultural factors -Cohen & Mao, (2014)

10 Both emotional distress (i.e. emotional pain) and physical pain activate the same brain regions leading to pain affect, pain behaviors, and the stress response.

11 What is psychological trauma?

12 an experience which within a short period of time presents the mind with an increase of stimulus too powerful to be dealt with in the normal way Freud, 1917

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14 The experience of an event that is emotionally painful or distressful which often results in lasting mental and physical effects. - National Institute of Mental Health

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16 Trauma is a psychologically distressing event that is outside the range of usual human experience, often involving a sense of intense fear, terror and helplessness. - Bruce D. Perry, M.D., Ph.D.

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18 PTSD vs. Complex Trauma Complex PTSD results in impairment in developmental processes related to the growth of emotional regulation and associated skills in effective interpersonal behaviors. -A Developmental Approach to Complex PTSD, 2009

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20 Case Example: Rudy

21 Stress is essential to adaptation and survival If an experience is deemed traumatic (i.e. resulting in physiological and psychological dysregulation) or not, hinges on the type of stressor, and postexperience intervention from social support networks. Positive stress Tolerable stress Toxic stress Shonkoff, et al. 2012

22 Sareen et al. (2007). N=36,984 Participants with PTSD had significantly higher rates of Chronic pain conditions, upper respiratory, gastrointestinal disease, CFS, Cancer,

23 ACES Study suggests a score =/>4 Are correlated to 2/3 rd (67%) of all suicide attempts. 64% of adult suicide attempts, and 80% of child/adolescent suicide attempts. 500% increase in adult alcoholism and illicit drug abuse 260% more likely to have developed Chronic Obstructive Pulmonary Disease. (women) 900% more likely to become victims of rape. (women) 500% more likely to become victims of domestic violence. Doubles the risk for early death (0 aces, 60% live to or more aces, 3% live to 65)

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25 Drossman et. Al. (2000). 50% of women referred to a GI treatment center had been physically or sexually abused. Van Houdenhove et al. (2009). 64% of patients with FM or CFS had experienced one type of child or adult abuse---39% had experienced both, indicating a lifelong pattern of re-victimization/ Asmudson et al. (2002). Up to 50% of patients presenting to tertitary chornic pain clinics satisfy criteria for PTSD number likely higher when you incorporate trauma that does not meet PTSD criteria.

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27 Traumatic pain and physical pain are not connected --they are one in the same using the same neurological and nervous system elements.

28 Toxic Stress/Trauma can be a direct source of biological injury or disruption that may have lifelong consequences independent of whatever circumstances might follow later in life. In such cases, toxic stress can be viewed as the precipitant of a physiological memory or biological signature that confers lifelong risk well beyond its time of origin. Shonkoff et al. 2012, American Academy of Pediatrics.

29 The purpose of pain survival. Non-pharmacological treatments must, at some level, work to lower the survival threat of pain. Change perception of pain. Change meaning/value of pain (often by-proxy)

30 Trauma-informed care. How would we set up our programs and practice if we assumed that many patients presenting with chronic pain are also dealing with trauma from an early age?

31 "What's wrong with you?" vs. "What has happened to you? Make the relationship with patient the primary intervention.

32 Talking to patients about pain Psychoeducation Concrete skills Relaxation and breathing exercises

33 Discussion, Questions, Difficult Patients.